Saturday, November 06, 2010

On AMIA's Jan. 2009 Letter to The Office of President Elect Barack Obama: Something is Missing

Nov. 11, 2010 note: see the new post on an AMIA Board Position Paper released this day (Nov. 11) entitled "Report of an AMIA special task force on challenges in ethics, safety, best practices, and oversight regarding HIT" at this link.

I was somewhat taken aback by the appearance of the article by Karsh et al. entitled "Health information technology: fallacies and sober realities" (covered at Healthcare Renewal here) in the Oct. 2010 Journal of the American Medical Informatics Association (JAMIA).

I was taken aback since the article rains heavily on the academic memes of healthcare IT as a benign and deterministic solution to healthcare's ills, and of health IT-related adverse outcomes being mere "anecdotes."

(It is ironic that my own relative recently fell victim to healthcare IT's supposed beneficence. They were harmed via health IT-related disruptions in care continuity.)

My blog posting on that Karsh article brought a letter to my attention, authored by AMIA's leadership and sent on Jan. 7, 2009 to the Office of President Elect Barack Obama. The full PDF of the letter is here.

Here are relevant excerpts about which I will make only a single comment:

January 7, 2009

Dear Mr. President-Elect,

On behalf of the more than 4,000 physicians, nurses and other members of the American Medical Informatics Association (AMIA) who use health information and communications technology (HIT) to improve the quality, efficiency and safety of healthcare, I am writing to applaud and encourage your commitment to investing in a genuine transformation of our nation’s healthcare system. Properly deployed and supported, HIT can be part of broad health care reform and, importantly in this time of economic challenge, a significant economic multiplier that will encourage the creation of new jobs and real improvements in patient care, public health and life sciences research.

... If we are to develop a national infrastructure for the use of health information to benefit individuals and our entire population, the United States must –

  • Develop mechanisms, including grants, loans and financial incentives for physicians, nurses, and healthcare organizations to deploy, implement successfully, and widely disseminate electronic health records (EHRs);
  • Develop and support local, regional and national health information exchange to ensure that accurate, secure health information is available whenever and wherever needed by those authorized to access such information;
  • Develop and support programs to address the need for a prepared health information technology workforce, with training and continuing education of physicians, nurses, health information managers and others;
  • Develop more effective ways to address the health needs of underserved populations, including providing equitable access to health information and communications technology;
  • Develop and assure compliance with standards, policies and practices that support effective sharing of health information, while fostering security, confidentiality and transparency, and building trust with the public;
  • Develop and maintain health terminologies and classifications that will allow health data to be not only useful, but uniform and consistent, and enable interoperability across myriad information systems;
  • Develop proper means to link information related to individuals in order to ensure the validity and integrity of health data used to inform care and research;
  • Develop proper means for authentication of the identity of individuals and caregivers and any others authorized to access identifiable health information;
  • Support the development of decision-making and other knowledge-management tools in order to permit the delivery of individualized, evidence-based care;
  • Develop and support secure web-portals to link individuals to their caregivers and ensure genuinely patient-centered care;
  • Develop appropriate and secure linkages between EHRs and the public health system to ensure safety from bioterrorism, rapidly spreading infectious diseases, and other threats;
  • And provide appropriate funding for the development of a robust national health information strategy, with support for continued HIT and informatics research and innovation.
During the Presidential campaign, you demonstrated your boldness and vision by pledging to allocate $10 billion annually for five years to promote the adoption and use of health IT. Such an investment will pay dividends not only in improving health care, but in creating jobs...

These are all laudable and interesting goals for an experimental technology, as tacitly admitted in the above goals (although it would have been more ethical, I believe, to have waited for the technology to have "needed" fewer of these goals as a result of research in constrained settings before boldly promoting expensive national rollouts on live patients).

In any case, however, something very, very important is missing...

There is no mention of healthcare IT safety.

At $10 billion annually, surely the AMIA leadership could have specifically and explicitly recommended that some fraction, even a token % (even a small percentage of $10,000,000,000 is not chicken feed), should have been dedicated to help ensure the disruptions and unintended consequences caused by any new/developing/expanding information and communications technology (ICT) didn't kill or maim patients.

Perhaps through the publication of the aforementioned Karsh study on HIT fallacies and sober realities, the AMIA leadership is subconsciously seeking absolution.

-- SS

Addendum: my own Dec. 7, 2008 "Open letter to President Obama" on healthcare IT took a decidedly different approach, namely, I attempted to make the President-elect aware of numerous HIT "fallacies and sober realities":

... our government has been seduced by the promise, the potential, the Siren Song if you will of HIT, and shielded from information on its true challenges, difficulties, downsides and failures. An "irrational exuberance", a Syndrome of Inappropriate and Uninformed Overconfidence in Computers prevails in healthcare.

... [If HIT itself is not reformed,] billions of precious healthcare dollars that might be spent on “IT misadventure” in a time of unprecedented national financial challenges and hardships might simply be better spent on delivery of needed medical services, health insurance and other "safety net" interventions.

... healthcare’s defects cannot be effectively changed or reformed via healthcare IT, if that healthcare IT itself is defective.

AMIA leadership and I also differed on the issue of health IT regulation, as I posted in July 2009 at "JAMA letter: Health Care Information Technology, Hospital Responsibilities, and Joint Commission Standards." On that issue, JAMA published my commentary, not theirs.

-- SS


Anonymous said...

There is an illusion that medical care will be safer because it is managed by a computer. Paradoxically, EMRs, CPOEs, and CDSs have a septic effect on the entire health care team, from doctors, to nurses, to dieticians. The workflow alterations and disruptions they cause are not only impediments to safe care. They promote errors due to poor usability, screens of tiny font gibberish, and intrinsic defects in the software. Such hazards are not reported or recorded, nor are the injuries and deaths.

No group is providing any surveillance for safety. ZILCH.

Ignorance is bliss. The industry mantra is, whenever the entire system shuts down and the entire patient record vanishes, "but patient care was not affected".

The hospital administrators in partnership with the vendors agree to not disclose the adverse clinical events, and go so far as to threaten the doctors who complain with their form of "peer review" for disruptive behavior.

The financial conflicts obfuscating objectivity about which Dr. Poses writes comes home to roost in AMIA's corner suite.

How much money, exactly, does AMIA take in from the vendors (disclosure, please) and when is AMIA going to sign on to the ethics agreement of the specialty societies?

Anonymous said...

Obama gets his HIT advice from Glen Tullman. Why would he listen to any one else? The impending UK like HIT debacle in the US will be a problem for him in 2012. Thus, the Republicans may not want to change the path to HIT Hell.

Scot M Silverstein MD said...

Anonymous November 6, 2010 4:55:00 PM EDT writes:

How much money, exactly, does AMIA take in from the vendors (disclosure, please) and when is AMIA going to sign on to the ethics agreement of the specialty societies?

Good question. I do not know and am not sanguine that queries from me will provide answers.

-- SS

Anonymous said...

I a shocked, SHOCKED, that Obama ignored your crazy ranting.

Scot M Silverstein MD said...

Anonymous November 7, 2010 1:54:00 PM EST wrote:

I a shocked, SHOCKED, that Obama ignored your crazy ranting.

As he reminded all of us, he won.

-- SS